More than ten percent of patients treated in intensive
care units (ICUs) were at some point receiving what doctors deemed to be futile
care, in a new study.

In those cases, critical care doctors believed people
would never survive outside an ICU or that the burdens of their care
"grossly outweighed" any benefits.

And, researchers found, treating each of those patients cost
about R40 000 per day. "Many physicians find that the provision of
futile care is not only contradictory to their professional responsibility, but
harmful to patients," Dr Neil Wenger, director of the UCLA Healthcare
Ethics Center at the David Geffen School of Medicine, and senior author of the
study, said.

"The biggest issue, more important than the cost issue,
is the use of highly advanced medical care that was designed to rescue people
that instead gets used to prolong the dying process," such as ventilators
and medicines that raise blood pressure, he told Reuters Health.

For their study, Wenger and his colleagues first convened a
group of 13 doctors who worked in critical care to agree on a definition of
futile treatment.

Severely compromised
states

Categories included care for patients who were permanently
unconscious or for whom death was imminent, or treatment that could not achieve
the patient's goals.

Then, the researchers surveyed the attending critical care
specialist in five ICUs every day for three months about each of that doctor's
patients to find out how many were receiving futile care under the focus
group's definition.

During the study period, 36 doctors assessed 1 136 patients,
with an average of six assessments per patient. Of those patients, 123 or 11%
were determined to be receiving futile treatment, and another 98 (8.6%) were
perceived as receiving probably futile treatment.

Eighty-four of those
receiving futile care died before discharge, and another 20 died within six
months of their ICU stay, the researchers reported in JAMA Internal Medicine.

The rest were left in "severely compromised"
states, with many kept alive by machines. Wenger and his team calculated
hospital costs for futile care were about R40 000 per day, adding up to R26
million's worth of treatment provided unnecessarily.

Dr Michael Niederman, chair of the department of medicine at
Winthrop-University Hospital in Mineola, New York, said how often futile care
is provided is likely to vary between ICUs. "It's very difficult to come
up with a definition of futile care," he told Reuters Health.

Multi-drug resistant bacteria

"I think there are many things we do where, over time, we
realise we're unable to help the patient." Niederman, who has studied
futile care but wasn't involved in the new research, said. Along with the costs
of providing intensive care that is unlikely to help, there may be times when
such treatment hurts other patients as well.

For example, many
very sick patients in the ICU are on antibiotics, even if they don't currently
have an infection.

One study he cited showed one quarter of them developed
multi-drug resistant bacteria – which could then spread to other patients on
the unit. Of course, the researchers said, doctors are not making treatment
decisions on their own, and families may have different opinions on what
constitutes futile care, or when the benefits of treatment outweigh the
burdens.

"Many times family members have a sense of guilt and
responsibility to their loved ones and want everything done, and I think
many times they don't understand what it means to do everything,"
Niederman said.

"The implied
discussion here is, do we have the resources in this country to give people
care whenever they want it, regardless of whether we think the care has any
benefit?" he said. "That's a very difficult discussion." Wenger said that
for him the study highlights the importance of having conversations with
patients about their end-of-life care while they are still able to participate
in those talks. ”It's a very complex process making decisions for very ill
patients who are on the brink of death," he said. "The main message
is that early discussions and advance planning are absolutely critical."

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